Synopsis At 0936 eastern daylight time, a Cessna TU206G amphibious float-equipped aircraft, registration C-GGSG, was approximately three nautical miles west of Toronto/Lester B. Pearson International Airport (LBPIA), Ontario, on approach to Runway05, and was cleared to land and hold short of Runway33L. About one minute later a Northwest Airlines McDonnell Douglas DC-9-51 aircraft, registration N773NC (Flight NoNWA971) was authorized to taxi to position on Runway33L for departure. Shortly thereafter, the airport controller advised NWA971 that a Cessna206 would land and hold short of Runway33L, and then issued the take-off clearance. After the Cessna 206 touched down on Runway05, the controller issued taxi instructions to the pilot, with instructions to hold short of Runway33L. The Cessna pilot then informed the controller that he was going around because of a landing gear problem. The controller immediately instructed the Cessna pilot to commence a hard left turn. At the same time the Northwest Airlines flight crew, just after becoming airborne, observed the Cessna and initiated a right turn. The spacing between the aircraft was approximately 100feet lateral and 100feet vertical over the threshold of Runway15R, with NWA971 being higher. There were no injuries as a result of this incident. Ce rapport est galement disponible en franais. Minister of Public Works and Government Services 2004 Cat. No. TU4-12/2004E-HTML ISBN 0-662-36684-0 1.0 Factual Information 1.1 History of the Flight The Cessna 206 aircraft was on a visual flight rules (VFR)1 charter flight from Georgian Bay, Ontario, to Toronto/LBPIA with one pilot and three passengers on board. While sequencing the Cessna206 for arrival, the airport controller asked the pilot if he was able to land and hold short2 of Runway33L. The pilot acknowledged that he could do so. At 0936:153, the controller cleared the Cessna to land on Runway05 and hold short of Runway33L and advised that there would be a Boeing737, American Airlines Flight449 (AAL449), departing Runway33L. At 0936:44, AAL449 was cleared for take-off on Runway33L and the aircraft took off. (SeeAppendixA). During the final approach, the pilot of the Cessna206 selected the landing gear down; however, the right main landing gear green light did not illuminate, indicating that the right main landing gear had not extended or that it had extended but did not lock into position. The pilot continued the approach and recycled the landing gear in an attempt to receive the appropriate landing gear indication. Upon completion of the landing gear recycling, the aircraft was in the landing flare and the pilot again observed an inappropriate landing gear indication for landing. The aircraft voice gear advisory system also sounded. Northwest Airlines Flight 971 (NWA971), a McDonnell Douglas DC-9-51 aircraft with 2flight crew, 3cabin crew, and 104passengers on board was conducting an instrument flight rules (IFR) scheduled flight from Toronto/LBPIA to Minneapolis, Minnesota, U.S.A. At 0937:17, NWA971 was authorized to taxi to position and hold on Runway33L and was advised that the Cessna206 aircraft was about to touch down on Runway05 and would be holding short of Runway33L. At 0938:00, NWA971 was cleared for take-off and seven seconds later the flight crew began the take-off roll. The controller did not advise the pilot of the Cessna206 that a DC-9 aircraft was departing from Runway33L. The Cessna206 touched down momentarily at 0938:36, approximately 1680feet past the threshold of Runway05, with approximately 3350feet of runway remaining prior to the intersection of Runway33L. The controller saw the touchdown, assumed the aircraft had landed, and instructed the pilot to continue taxiing on Runway05. He also reminded the pilot to hold short of Runway33L. Eight seconds later, the pilot announced that he was going around because of a landing gear problem. The controller immediately instructed the Cessna pilot to commence a hard left turn to a heading of 290. During the go-around, the Cessna206 passengers observed the McDonnell Douglas DC-9 aircraft on its take-off run, and the front seat passenger alerted the pilot to the conflict. The point of rotation of NWA971 was near taxiway Foxtrot2, and, as the aircraft commenced its climb, the first officer, the pilot flying, observed the approaching Cessna206 aircraft. He alerted the captain and took immediate evasive action to the right. A review of the recorded radar data indicated that the spacing between the aircraft was approximately 100feet laterally and vertically over the threshold of Runway15R. After the incident, the Cessna206 was vectored west and south of Toronto/LBPIA to a landing in the harbour at Toronto Island, and the DC-9 aircraft proceeded to Minneapolis, as planned. 1.2 Personnel Information 1.2.1 Cameron Air Service Cessna 206 C-GGSG The Cessna pilot held a Commercial Pilot Licence and was the owner/operator of Cameron Air Service, which operated a fleet of three Cessna206 aircraft and two Cessna208 Caravan aircraft. He had been a licensed pilot for 25years and had accumulated a total of 7500hours. Most of his flying hours were on the occurrence aircraft type. The occurrence flight was his first flight of the day and he had had the previous 24hours off duty. 1.2.2NorthwestAirlinesMcDonnellDouglasDC-9N773NC The Northwest Airlines captain held an Airline Transport Pilot Licence. He was seated in the left seat of the McDonnell Douglas DC-9-51 aircraft and was the designated pilot not flying. The Northwest Airlines first officer held an Airline Transport Pilot Licence. He was seated in the right seat of the aircraft and was the designated pilot flying. 1.2.3 Air Traffic Controller The airport controller started his air traffic control career in the military in1988 and became a civilian air traffic controller in1991. He had controlled at Toronto/LBPIA for 3years. On the day of the occurrence, he had been on duty for 4hours and, after returning from a break, had worked in the airport control position for 45minutes. He had been off duty for 15hours prior to the start of his shift. 1.3 Aircraft Information 1.3.1 Cameron Air Service Cessna 206 C-GGSG Inspection of the landing gear by Eagle Aircraft Inc., based at Toronto/City Centre Airport, revealed that the right main gear actuator link, P/N:3A05518-001, was broken off at the end of the threaded shank. When the actuator runs to the end of its travel, the jam nut at the end of the threaded shank rests against the stop. The over-centre travel then makes the jam nut act as the fulcrum, causing a slight bending moment on the link. The numerous cycles caused the link to crack and finally break. The jam nut was also interfering slightly with the stop. 1.3.2NorthwestAirlinesMcDonnellDouglasDC-9N773NC 1.4 Meteorological Information The Aviation Routine Weather Report (METAR) for Toronto/LBPIA issued at 1300 hours UTC reported the wind from 360 true at 9knots, visibility 15statute miles, a few clouds at 4000feet, a few clouds at 25000feet, temperature 21C, dew point 16C and the altimeter setting 29.95in.Hg. The weather at the time of the occurrence was good visual meteorological conditions (VMC) and was not considered to be a factor. 1.5 Aids to Navigation There were no reported problems with the aids to navigation. 1.6 Communications There were no communications equipment discrepancies noted or reported that would have contributed to the occurrence, and neither aircraft experienced communications malfunctions or difficulties. The NWA971 flight crew reported that they heard the controller communication directed to the Cessna206 pilot; however, the Cessna206 pilot's response was not heard. 1.7 Aerodrome Information 1.7.1 General The Toronto/LBPIA has five main runways. The fifth runway was under construction at the time of the occurrence and was commissioned on 19October2002. The orientation and length of the runways are depicted in AppendixA. The distance from the threshold of Runway05 to the intersection of Runway 33L is approximately 5030feet. The distance from the threshold of Runway33L to the intersection of Runway05 is approximately 7424feet. At the time of the occurrence, all runways were bare and dry. The following operations can be conducted under simultaneous intersecting runway operations (SIRO), now commonly called land and hold short operations (LAHSO): Land 05 hold short 33R/15L Land 33R hold short 05/23 Land 33L hold short 05/23 1.7.2 GTAA Guidelines For The Use Of Runways 15R/33L and 15L/33R Runways 33L and 33R are not available for routine departure and arrival operations because of restrictions imposed by the Greater Toronto Airports Authority (GTAA) for noise mitigation purposes. The use of north/south runways continues to be a noise sensitive issue for the GTAA and, as a result, GTAA provided NAV CANADA with guidelines for the use of these runways. As a result of the closure of the south parallel runway for construction the GTAA stipulated either a single-runway or crossing-runway operation. The air carriers prefer not to use Runway 05 for departures because the taxi distance from the ramp to Runway05 is considered excessive and adds considerably to taxi times and wear and tear on the aircraft. 1.7.3 Air Traffic Control Tower Personnel Staffing The Toronto/LBPIA tower staffing was established for north tower, north ground, south tower, south ground, clearance delivery and supervisor positions. The south tower and south ground positions were closed because of the runway configuration in use, that is, aircraft departures from Runway33L and aircraft arrivals on Runway05. The supervisor was conducting an over-the-shoulder check on the ground controller at the time of the occurrence. The north tower controller assessed the traffic volume to be light; however, the operation was complex because of the runway configuration. Near the time of the occurrence, the north tower controller's workload consisted of approximately 15-20departure aircraft and two arrival aircraft. 1.8OrganizationalandManagementInformation 1.8.1Sequential and Simultaneous Operations on Intersecting Runways 1.8.1.1 General Air traffic control (ATC) procedures allow for sequential and/or simultaneous operations on intersecting runways. These operations differ in the controllers' application of ATC procedures, and ATC advisories will specify the type of operation(s) in progress. 1.8.1.2 Sequential Intersecting Runway Operations The Air Traffic Control Manual of Operations (ATC MANOPS), Section352.4, instructs controllers to separate an arriving aircraft from another aircraft using an intersecting runway, or non-intersecting runway if flight paths intersect. This is done by ensuring that the arriving aircraft does not cross the landing threshold or flight path of the other aircraft until a preceding departing aircraft has passed the intersection or flight path or turned to avoid any conflict. ATC MANOPS352.5 instructs controllers to separate a departing aircraft from an aircraft using an intersecting runway, or non-intersecting runway if flight paths intersect. This is done by ensuring that the departing aircraft does not begin its take-off roll until a preceding arriving aircraft has taxied off the landing runway, completed the landing roll and will hold short of the intersection (the preceding aircraft need not be stopped as long as it has decelerated to taxi speed before the succeeding aircraft begins the take-off roll and it will not enter the runway or cross the flight path being used by the departing aircraft), passed the intersection, or crossed over the departure runway. 1.8.1.3SimultaneousIntersectingRunwayOperations ATC MANOPS352.6 states that controllers may authorize simultaneous landings or a simultaneous landing and a take-off on intersecting runways provided the procedure is approved in unit directives and other specified weather and operational conditions exist. Aeronautical Information Publication (A.I.P. Canada) Section RAC 4.4.9(b) lists three of the conditions as follows: The landing distance available (LDA), measured from the threshold or displaced threshold to 200feet short of the nearest edge of the runway being intersected, must be published in the Canada Air Pilot and in the Canada Flight Supplement. (The information would appear on the aerodrome charts of each publication.) ATC shall broadcast LAHSO advisories, including LDAs, through an automatic terminal information service (ATIS) or voice advisory, well in advance of the final approach descent. ATC must include specific directions to hold short of an intersecting runway. The ATC MANOPS uses the term simultaneous intersecting runway operations (SIRO). The simultaneous use of Runway05 for landings and Runway33L for take-offs was not authorized in unit directives. Currently, there are no provisions in the Canadian Aviation Regulations (CARs) for LAHSO. When CARs were developed, LAHSO procedures were not included with the exception of aerodrome marking and signage considerations. LAHSO procedures were agreed to and standardized in1991, and were published in Air Navigation System Policy Document (TP9474). Operations procedures were then included in the ATC MANOPS and the A.I.P. Canada. With privatization of the air navigation system in1996, TP9474 was no longer in effect and operational procedures for LAHSO continued to be governed by the ATC MANOPS and the A.I.P. Canada. The operational implementation for LAHSO was governed by the Air Navigation Services and Airspace Policy and Procedures Manual and the Air Traffic Services Administration and Management Manual. Notice of Proposed Amendments2001-260 to2001-263 were developed as LAHSO regulations for consideration by the Canadian Aviation Regulation Advisory Council (CARAC); however, unanimous agreement by all in the working group could not be reached. Transport Canada (TC) has since decided to withhold the consultation process and to conduct a risk assessment of LAHSO. The risk assessment process is ongoing and will be evaluated at a future CARAC working meeting. 1.8.2 NAV CANADA Bulletin ATCI: 2000-1 NAV CANADA issued Information Bulletin ATCI: 2000-1, effective 20 July 2000, entitled Airline Pilots Association Position on SIRO, which states in part: SIRO in Canada is not governed by regulation except for the CARs, Part III standards, with respect to aerodrome markings and signage. By working within the Canadian regulatory system and by participating in the FAA LAHSO procedures development process, ALPA officials believe they have identified minimum standards of safety against which SIRO must be measured before air carrier pilots accept SIRO. The minimum safety standards as described by ALPA officials deal with adequate landing distances, markings and signs, rejected landing procedures, pilot training and runway conditions. It is ALPA's belief that these standards have not been addressed in Transport Canada's recently proposed change to the CARs or by the actions already taken by the FAA for LAHSO. SIRO in Canada is not governed by regulation except for the CARs, Part III standards, with respect to aerodrome markings and signage. By working within the Canadian regulatory system and by participating in the FAA LAHSO procedures development process, ALPA officials believe they have identified minimum standards of safety against which SIRO must be measured before air carrier pilots accept SIRO. The minimum safety standards as described by ALPA officials deal with adequate landing distances, markings and signs, rejected landing procedures, pilot training and runway conditions. It is ALPA's belief that these standards have not been addressed in Transport Canada's recently proposed change to the CARs or by the actions already taken by the FAA for LAHSO. 1.8.3 Squawk 7700 NAV CANADA issued Squawk 7700 NP 8493, an Air Traffic Services bulletin, effective 26 October 2000, entitled Deviation from Established ATS Procedures. It states in part: It is the responsibility of all ATS personnel to adhere to established procedures. You may deviate from a procedure if the situation warrants but, if you do, the outcome cannot be predicted with any certainty if all the elements in planning, executing, and monitoring are not satisfied. There is always an associated increase in the risk of separation losses or collisions when these situations occur; therefore, ad hoc deviations from established procedures as a normal method of operation for the sole purpose of expediting air traffic should be avoided. If there is a continuous need to disregard or alter a procedure then it may not be as effective or efficient as it could be and a change may be warranted. 1.8.4 Airline Pilots Association, International (ALPA) Position on SIRO/LAHSO One of ALPA's continuing concerns with LAHSO is the need for acceptable rejected landing procedures. For the purposes of LAHSO, a rejected landing may occur when the pilot in command elects to go-around, having determined that a full stop landing at the hold short point is not assured because of an emergency situation, an unsafe condition on the runway of intended landing exists, or the aircraft is not properly configured to complete a full-stop landing within the LDA. In Canada, there are no published procedures for aircraft to follow in the event a go-around is necessary after the pilot has accepted a hold-short clearance. The A.I.P. Canada Section RAC 4.4.9 (c), NOTE states: During sequential and/or simultaneous operations, ATC procedures and pilot compliance with clearance conditions will ensure aircraft separation (i.e., spacing between aircraft). Notwithstanding this, conflicts between aircraft may occur, particularly at runway intersections, if a pilot does not comply with a clearance or is unable to comply as a result of unforeseen circumstances, such as missed approaches, misjudged landings, balked landings or brake failures. In these circumstances, ATC will endeavour to provide traffic advisories and/or instructions to assist pilots with collision avoidance. 1.8.5 TC's Air Traffic Services Standards Division Audit and Inspection Responsibilities To ensure the continued safe operation of the Canadian air navigation system, TC has created the Office of Air Navigation Services and Airspace Safety Oversight, tasked with the custody of the air navigation and airspace safety oversight policy and program. The goal of the safety oversight function is to advance safety by: continuously monitoring the national civil air navigation system and environment; reducing the likelihood of accidents and incidents; and discouraging non-compliant behaviour or practices. Air traffic services audits are conducted as required and results are forwarded to NAV CANADA for information and corrective action, as required. In September 2001, TC conducted a regulatory inspection of the Toronto Control Tower. The purpose of this inspection was to verify compliance with established requirements in keeping with the procedures described in the ATC MANOPS. General airport control procedures were reviewed with a special focus on the provision of simultaneous intersecting runway operations / land and hold short operations. A review of recorded communications relating to LAHSO operations revealed deviations from the ATC MANOPS. Subsequently, NAV CANADA issued Operations Bulletin No01-72 as a mandatory briefing for staff in order to ensure compliance with the ATC MANOPS direction concerning the following issues: use of LAHSO if the braking action reported is less than good, correct traffic information exchange during sequential and LAHSO operations, and the alternation between sequential and simultaneous operations. 1.9 Additional Information 1.9.1 Aerodrome Charts The Canada Air Pilot aerodrome chart for Toronto/LBPIA presents a text box entitled LDA for Simultaneous Runway Operations. The text box indicates the LDA for three different runway configurations, but the LDA from the threshold of Runway05 to the intersection of Runway33L is not depicted. Therefore, at the time of the occurrence, the use of LAHSO was not authorized for arrivals on Runway05 and departures off Runway33L. A review of the Jeppesen charts (used by the Northwest Airlines flight crew) revealed that LAHSO is depicted for Canadian airports by use of a text table with the terminology Additional Runway Information. Runway useable lengths (or in Canada, LDA) applicable to LAHSO is depicted as follows: Threshold to Intersecting Runway terminology is used for 14Canadian airports, and LAHSO Distance terminology is specifically identified for 2Canadian airports. There is no LAHSO data depicted for 2Canadian airports which authorize LAHSO operations. The title used on the Jeppesen chart for Toronto/LBPIA is Threshold to Intersecting Runway. 1.9.2 Wake Turbulence Separation Either four miles or three minutes wake turbulence separation is required between a light aircraft (Cessna206) and a medium aircraft (B737orDC-9). Low, slow flying aircraft are at an increased risk of loss of control and collision with the ground when flying into a wake vortex from a preceding aircraft.